Advanced Therapies

Advanced Therapies is the division of Rochester Radiology dedicated to the field of Vascular and Interventional Radiology.

This field utilizes state-of-the-art images to guide our highly trained specialists, called interventional radiologists, to perform minimally invasive procedures. Many of these procedures are performed through the tiniest of nicks in the skin – without surgical incisions – allowing for interventions which, only a few years ago, would have required open surgeries and the risks that often accompany them.

Common procedures performed by our board-certified interventional radiologists:

Uterine Fibroid Embolization (UFE)

What are fibroids and why do they cause so many symptoms?

To describe fibroids and UFE, let’s start an analogy. Imagine you have a beautiful garden full of flowers. Now imagine that some tiny weeds start growing right in the middle of that garden. While small, the garden is not affected. But as years go by, with roots spread out, those pesky weeds now steal water, sunlight, and nutrients from other plants, and completely disrupt the delicate balance of the garden. Flowers are displaced and slowly start to wilt from lack of water and sunlight. The entire fabric of that garden is now in disarray.

This situation is analogous to what a fibroid does to the uterus. Fibroids are benign (noncancerous) growths that occur in the uterus. They are exceedingly common in women over 35, with up to 50% of all women in this age range having them. They range in size from smaller than a pea to as large as a football, causing the uterus to grow to the size of a five to six month pregnancy. In most cases, there are multiple fibroids in a uterus. Symptoms include heavy menstrual bleeding, pelvic or back pain, bloating, and bladder or bowel pressure causing frequent urination or even constipation. Due to this nonspecific group of symptoms, many women are unaware that their symptoms are from fibroids. Fibroids are hormonally driven, and therefore can grow rapidly during periods of elevated hormone states such pregnancy, and conversely may start to decrease in size after menopause.

Let us revisit how those weeds affect the garden. A small patch of weeds generally would not cause much trouble, and may even go unnoticed. But when those weeds grow large, their roots start to spread out and steal water and nutrients. They start pushing on the flowers. Similarly, only large and/or multiple fibroids generally require treatment. Typically, approximately 10-20% of fibroids are large enough to cause symptoms that require treatment; however, that still amounts to approximately 5-10% of all American women, many of whom do not realize the cause of these nonspecific symptoms.

So what can you do about those parasitic weeds which have now overrun the garden? If it was a single patch of weeds near the edge of the garden, simply pulling them out may be your answer. But be sure to get all the way down to the roots, otherwise regrowth is a possibility. Or, if the weed situation is so catastrophic, maybe pulling out the whole garden is the option. But what about a weed killer, a substance taken up selectively by the weeds (rather than the flowers) which then kills only the weeds? Different chemicals have long been known for their ability as herbicides to kill weeds specifically while not harming surrounding plants.

Similarly, there are multiple options for fibroids. If amenable in size and location, surgical removal called myomectomy of one or few accessible fibroids may be the best option while leaving the remainder of the uterus intact. For a uterus overrun with large fibroids that cause severe symptoms, many women choose removal of the entire uterus, called hysterectomy, as the ‘be all end all’ treatment. In fact, uterine fibroids are the most frequent indication for hysterectomy in premenopausal women; of the 600,000 hysterectomies performed annually in this country, one-third are due to fibroids. Other hormone-based options, albeit less definitive, also exist and include hormone therapy to shrink the fibroids versus waiting for menopause to naturally decrease hormone levels for the same result.

The final option is the medical version of weed killing, a relatively new option in the medical field over the past 20 years, called uterine artery embolization. Theoretically, the concept is exactly like a weed killer. Instead of introducing a substance into the water supply of the garden that is preferentially taken up only by weeds and which is toxic to them, small particles are injected into the uterine blood supply which are preferentially taken up by the fibroids as they try to steal the normal blood supply to the uterus, and which therefore selectively kills only their blood supply. Although some particles travel towards normal uterine musculature, the uterus will not die due to rich blood supply from other multiple areas.

What is Uterine Fibroid Embolization (UFE)?

Uterine fibroid embolization (UFE) is an minimally invasive treatment for uterine fibroids. The non-surgical procedure is performed by interventional radiologists to treat all fibroids present in a uterus causing symptoms, regardless of number or location. The origins of UFE came about after a French gynecologist sought an interventional radiologist to stop the blood supply to the uterus for his patients prior to their hysterectomies to minimize intraoperative bleeding. Soon, the gynecologist started to note that these patients were canceling their hysterectomies weeks before their surgeries as their symptoms were suddenly stopping. Follow-up evaluations demonstrated the fibroids were decreased in size but the uterus was unharmed. Thus, minimally invasive fibroid intervention was born.

You will initially come in for a consultation in our Advanced Therapies office to fully discuss the problem and all the treatment options to ensure that this is the right treatment for you. Usually, an ultrasound or MRI is done to confirm the size, location, and extent of your fibroids. On the day of the procedure, you will be prepped in the pre-procedure area and brought to the interventional radiology suite. Under local anesthesia, a tiny catheter (tube) is introduced into an artery in the groin and advanced under image guidance into the artery that feeds the uterus. There, tiny particles – smaller than grains of sand – are released. These particles are then preferentially taken up by the fibroids which tend to steal the uterine blood supply. With success rates routinely shown up to 94%, it has become a mainstay of fibroid treatment over the past 15 years. The procedure usually takes less than one hour, is performed with conscious sedation rather than general anesthesia, and can done as an outpatient procedure or as an overnight observation.

Are fibroids common?

Fibroids are exceedingly common in women over 35, with up to 50% of all women in this age range having them. Their incidence is even higher in African-American women. They range in size from smaller than a pea to as large as a football, causing the uterus to grow to the size of a five to six month pregnancy.

Will my fibroids require treatment?

Typically, only 10-20% of fibroids are large enough to cause symptoms that require treatment; however, that still amounts to approximately 5-10% of all American women, many of whom do not realize the cause of these non-specific symptoms.

What kind of treatments are available?

There are multiple options for fibroids. Surgical removal (called myomectomy) of one or a few accessible fibroids may be the best option for women with mild symptoms. For a uterus overrun with large fibroids that cause severe symptoms, women may choose removal of the entire uterus, called hysterectomy. In fact, uterine fibroids are the most frequent indication for hysterectomy in premenopausal women. Other medical options also exist and include hormone therapy to shrink the fibroids, versus waiting for menopause to naturally decrease hormone levels for the same result.

The final option is uterine fibroid embolization. Uterine fibroid embolization (UFE) is an minimally invasive treatment for uterine fibroids. The non-surgical procedure is performed by interventional radiologists to treat all fibroids present in a uterus causing symptoms, regardless of number or location. Under local anesthesia, a tiny catheter (tube) is introduced into an artery in the groin and advanced under image guidance into the artery that feeds the uterus. There, tiny particles – smaller than grains of sand – are released. These particles are then preferentially taken up by the fibroids which tend to steal the uterine blood supply. With success rates routinely shown up to 94%, it has become a mainstay of fibroid treatment over the past 15 years.

What are the risks of this procedure?

The risks of the UAE include risk of bleeding, clot, and infection. Non-target embolization refers to particles being injected into an unintended area. The effects of UAE on fertility have long been a question mark. Although many women clearly preserve their fertility and have children after UAE, there are no long-term scientific studies proving this. However, fibroids themselves are a cause of infertility in younger women, and a hysterectomy obviously eliminates any chance of preserving fertility, thus making UAE a viable option for many.

How long will it take me to recover?

Most of our UFE patients are admitted overnight to monitor them and to treat post-embolization syndrome, which includes abdominal pain and cramping, nausea, fever, and malaise. Many patients state that this recovery, which usually only lasts overnight, is similar to the flu. We usually keep women overnight to ensure they are comfortable and provide any medications that they may need until the post-embolization syndrome resolves. However, many of our patients now have minimal post-procedure pain and choose to go home the same day.

Before the procedure, I couldn’t sleep in bed and had to sleep in a chair … afterwards, I have been able to sleep in bed and get up independently the majority of the time. I still have some pain, but take less pain medications, and my quality of life has improved.

As opposed to an open surgery, it is done through two tiny nicks in the back. It can be performed as an outpatient procedure without general anesthesia, and requires minimal recovery. In fact, the goal is for most bedbound patients (who were previously unable to walk because of pain) to attempt walking hours after the procedure in our recovery area.

How is the balloon kyphoplasty performed?

Balloon kyphoplasty is performed by an interventional radiologist, who is a physician with expertise in minimally invasive procedures using imaging guidance. It is performed in an Angiography Suite that looks like an operating room, but has a small tube over it, which provides real-time x-ray imaging for the procedure.

Treatment for each vertebral compression fracture level typically takes less than one hour. Multiple fractures can be treated simultaneously, usually up to 3 levels in one procedure, except in special circumstances.

It can be performed on an inpatient or outpatient basis and is usually performed with conscious sedation or simple local analgesia only (lidocaine injection in the skin). It rarely requires general anesthesia. Your physician will discuss which options are appropriate for you.

What actually takes place during the procedure?

The procedure involves placing a metal cannula (about the size and diameter of a pencil) into the vertebral body to be treated using careful image guidance. Once the cannula is placed, the inner stylet is removed and a small balloon is advanced through the hollow trocar. The balloon is carefully inflated under visualization, creating a cavity in the bone and condensing the bone around it, while trying to restore height to the vertebral body (reducing the fracture).

Finally, a special ‘bone cement’ called polymethylmethacrylate (PMMA) is injected into the bone. Injecting the bone cement has three purposes:

1. As it hardens, it fixates the fractured portions of the bone. (Fractured bone movement is what causes the pain.)

2. It solidifies the structural rigidity of this portion of the spine that was acting as the “weak link in the chain”.

3. The heat given off as the cement hardens has been hypothesized to burn tiny little nerve endings, which in turn reduces the pain.

How does balloon kyphoplasty differ from vertebroplasty?

Balloon kyphoplasty is similar to vertebroplasty; however, vertebroplast does not include balloon inflation as a way to create a cavity prior to injection of the bone cement. Instead, the bone cement is directly injected into the bone after the cannula is placed. As no cavity is created, the bone cement injected needs to be thinner and under pressure, which equates to more risk for cement to leak out of the bone. In addition, no balloon inflation reduces the chance of restoration of height of the vertebral body.

Is balloon kyphoplasty covered by insurance?

In general, kyphoplasty is covered by insurance providers. However, each provider has different requirements, such as a trial a of conservative therapy with rest, pain medications and/or a back brace prior to undergoing this procedure. Consult with your health insurance provider for further information.

How long will it take me to recover?

Balloon kyphoplasty is generally performed as an outpatient procedure. Following the procedure, you are transferred to the Interventional Radiology recovery area for four hours for observation. After your sedation completely wears off, (usually within two hours) you will be asked to attempt walking if your pain has already subjectively improved. Your interventional radiologist will have a specific post-operative recovery/exercise plan to help you return to your normal daily life as quickly as possible.

Patients usually report relief from pain and are able to walk and move about soon after the procedure. Your doctor will schedule a follow-up visit and explain limitations, if any, on your activity.

Following a balloon kyphoplasty, you may notice a rapid improvement of some or all of your symptoms — including pain — while other symptoms may improve more gradually. You will work closely with your physician to determine the appropriate recovery protocol for you, and follow his or her instructions closely to optimize the healing process.

What are the potential risks or complications of this procedure?

Although the complication rate for balloon kyphoplasty is very low, as with most other surgical and minimally invasive procedures, serious adverse events can occur, some of which can be fatal. The following are the minor and major serious risks.

Minor risks and complications are more common than severe and may include, but are not limited to: bleeding/small hematoma on back, minor skin infection at site of injection, leakage of a small amount of “cement” into the adjacent disc space, and lack of pain relief despite successful technique during the procedure.

In more rare instances, major risks and complications may occur. These include: cement embolism (leakage of the cement out of the vertebral body and migration to the lungs); paralysis (due to spinal cord damage as a result of the placement of the cannula); leakage of bone cement into the spinal canal and/or surrounding nerves (may also result in paralysis); severe infection of the vertebral body, disc space or spinal canal; bleeding/hematoma in or surrounding the spinal canal, thus compromising the spinal cord.

Does having a balloon kyphoplasty increase my risk for more vertebral fractures?

No.

Chemoembolization

What is chemoembolization?

Chemoembolization is a minimally invasive procedure performed by an interventional radiologist that directly targets tumors in the liver. It works by complimentary means, first injecting chemotherapy directly into the tumor, and then stopping the blood supply to the tumor. This double-injury method causes cell destruction of the tumor while sparing normal liver tissue and reducing side effects of chemotherapy elsewhere in the body. Sometimes, a third injury technique is added for certain cases, in which the tumor is ablated using either a freezing (cryoablation) or heating (radiofrequency ablation) method.

How is the chemoembolization performed?

You will initially come in for a consultation in our office to fully discuss the problem and all the treatment options to ensure that this is the right treatment for you. Prior to your procedure, labs and a special type of CT called a CT angiography will be performed to evaluate and map the tumor and all the arteries leading to it.

On the day of the procedure, you will be prepped in the pre-procedure area and brought to the interventional radiology suite. Under local anesthesia, a tiny catheter (tube) is introduced into an artery in the groin and advanced under image guidance into the livery artery that feeds the tumor. There, tiny particles – smaller than grains of sand – are released. These tiny particles have a specific chemotherapy attached to them tailored to the specific type of tumor. These particles are then preferentially taken up by the liver tumors which tend to steal the normal liver blood supply. Chemoembolization has become a mainstay of liver tumor treatment over the past 20 years. The procedure usually takes less than 1-2 hours, is performed with conscious sedation rather than general anesthesia, and usually only requires an overnight stay for observation.

How long will it take me to recover?

Chemoembolization is a minimally invasive procedure, with no surgical incision, therefore greatly reducing the time needed for recovery. Recovery from the catheterization usually involves 4 hours of bedrest in the recovery area keeping the legs straight. Recovery for the chemoembolization of the tumor usually involves overnight observation for post-embolization syndrome. This includes abdominal pain and cramping, nausea, fever, and malaise. Many patients state that this recovery, which usually only lasts overnight, is similar to the flu. We keep patients overnight to ensure they are comfortable and provide any medications that they may need until the post-embolization syndrome resolves.

What are the potential risks or complications of this procedure?

The risks of the chemoembolization include risk of bleeding, clot, and infection. Non-target embolization refers to particles being injected into an unintended area, but is rare if being performed by an experienced physician. Liver failure is also a possible complication, which is why labs will be drawn and full medical history explored during your initial consultation to ensure you are a proper candidate.